Fluidics - Safe Work Practices Forms (ver2.0)

• Work Order/Job Number# and Task, (i.e. - #123456 - Pipe Fabrication/Welding, or #123456 - 7 Ton Package unit Troubleshooting)

• Tap and check off all completed forms for this audit

  Select Pre-Task Planning Checklist Vehicle inspection Checklist due the first of the month Pre-Task Planning Guide New Hire Orientation Mandatory Safe work Practices EM&FS field Safety Inspection Report Root Cause Analysis Worksheet

  • Pre-Task Planning Checklist
  • Vehicle inspection Checklist due the first of the month
  • Pre-Task Planning Guide
  • New Hire Orientation
  • Mandatory Safe work Practices
  • EM&FS field Safety Inspection Report
  • Root Cause Analysis Worksheet

Pre Task Planning Checklist

• Date

  Date

• Tradesman Name(s)

PPE & Safety Equipment Needed

• Eye and Face - Safety glasses, goggles, face shield

  Yes

  Not Applicable

• Head/ear - Hard hat, bump cap, ear plugs

  Yes

  Not Applicable

• Hand: Gloves, leather, gauntlet, cut or chem resistant

  Yes

  Not Applicable

• Fall Protection/Restraint - Harness/Lanyard/Anchor

  Yes

  Not Applicable

• NFPA 70E Arc Flash Protection Gear when performing electrical investigative/troubleshooting activities with the power on. Live manipulative work with the power on is not permitted

  Yes

  Not Applicable

• Welding - goggles, hood, sleeves, gloves.

  Yes

  Not Applicable

• Knee/shin/foot (safety toe, rubber soles, knee pads)

  Yes

  Not Applicable

• Ground fault circuit interrupter

  Yes

  Not Applicable

• Lock out tag equipment

  Yes

  Not Applicable

• Fire Extinguisher

  Yes

  Not Applicable

• Pedestrian control: signs, caution tape, cones

  Yes

  Not Applicable

Work Site Inspection - Before Work Proceeds

• Customer safety guidelines, permits, pick plans

  Yes

  Not Applicable

• Acceptable access, egress, escape route

  Yes

  Not Applicable

• First aid station available

  Yes

  Not Applicable

• Emergency phone numbers - KNOW YOUR ADDRESS and LOCATION AT YOUR SITE, Usually 911 but check with customer to see if there are in house emergency numbers.

  Yes

  Not Applicable

• Proper illumination

  Yes

  Not Applicable

• Trash recepticles

  Yes

  Not Applicable

• Tripping and slipping hazards identified

  Yes

  Not Applicable

• Unprotected edge, skylight, other fall hazards

  Yes

  Not Applicable

• Confined space

  Yes

  Not Applicable

• Weather conditions acceptable for outdoor work

  Yes

  Not Applicable

• Do you have the correct manpower to proceed

  Yes

  Not Applicable

Tools and Equipment Inspection Prior to Task

• Ladders

  Safe

  At Risk

  N/A

• Hand and power tools

  Safe

  At Risk

  N/A

• Material handling equipment

  Safe

  At Risk

  N/A

• Gantry, chain fall, slings or other lifting equipment

  Safe

  At Risk

  N/A

• Scaffolds

  Safe

  At Risk

  N/A

CRANES

• Are you using a Crane today?

  Yes

  Not Applicable

• Photos of Operators Certification, Annual inspection, daily checklist

  Media

• Barricaded outriggers

  Yes

  No

  N/A

• Overhead power lines protected or de-energized

  Safe

  At Risk

  N/A

• Synthetic slings not showing any signs of wear, worn spots, indicator threads?

  Safe

  At Risk

  N/A

• Are they the right sling for the job, rated, proper angles, not to short or long?

  Safe

  At Risk

  N/A

• Load labels present and legible on all slings

  Safe

  At Risk

  N/A

• Free of abnormal wear patterns or damage

  Yes

  No

  N/A

• Placed on good lifting points

  Yes

  No

  N/A

• Have all loose items been removed from the load, or secured to the load.

  Yes

  No

  N/A

• Tag lines on all loads

  Safe

  At Risk

  N/A

• Long enough

  Safe

  At Risk

  N/A

• Free of knots

  Safe

  At Risk

  N/A

• Lifting points center the load

  Yes

  No

  N/A

• Is load going over a high risk area, ( I.e. Chemical, lines, hazardous equipment, etc.)

  Safe

  At Risk

  N/A

• Copy of lift plan available on site for complex or high risk lifts

  Yes

  No

  N/A

• Travel path clear of people

  Safe

  At Risk

  N/A

• All are same size and rating

  Yes

  No

  N/A

• Is the spread correct for the application

  Safe

  At Risk

  N/A

• Slings free of pinched cables, bird caging, broken strands

  Safe

  At Risk

  N/A

MANLIFTS

• Are you using a manlift today. Perform an inspection each day prior to use.

  Yes

  Not Applicable

• MONDAY

• Type of lift

  Select Scissor Mast Articulated Boom

  • Scissor
  • Mast
  • Articulated Boom

• Model#

• Oil Level

  Safe

  At Risk

  N/A

• Hydraulic oil level

  Safe

  At Risk

  N/A

• Fuel level

  Safe

  At Risk

  N/A

• Ground control switches

  Safe

  At Risk

  N/A

• Tire condition

  Safe

  At Risk

  N/A

• Coolant level

  Safe

  At Risk

  N/A

• Batteries

  Safe

  At Risk

  N/A

• Leaks? Look under lift

  Safe

  At Risk

  N/A

• Horn

  Safe

  At Risk

  N/A

• Gauges

  Safe

  At Risk

  N/A

• Brakes

  Safe

  At Risk

  N/A

• Lights

  Safe

  At Risk

  N/A

• Attachments and accessories

  Safe

  At Risk

  N/A

• Steering

  Safe

  At Risk

  N/A

• Back up alarm or warning buzzer

  Safe

  At Risk

  N/A

• Warning lights

  Safe

  At Risk

  N/A

• Lift and travel control switches

  Safe

  At Risk

  N/A

• Placards, decals and control ID present and legible

  Safe

  At Risk

  N/A

• Handrails, guardrails and safety chains

  Safe

  At Risk

  N/A

• Platform deck and toe boards

  Safe

  At Risk

  N/A

• Electrical lift cords are in good condition

  Safe

  At Risk

  N/A

• TUESDAY

• Type of lift

  Select Scissor Mast Articulated Boom

  • Scissor
  • Mast
  • Articulated Boom

• Model#

• Oil Level

  Safe

  At Risk

  N/A

• Hydraulic oil level

  Safe

  At Risk

  N/A

• Fuel level

  Safe

  At Risk

  N/A

• Ground control switches

  Safe

  At Risk

  N/A

• Tire condition

  Safe

  At Risk

  N/A

• Coolant level

  Safe

  At Risk

  N/A

• Batteries

  Safe

  At Risk

  N/A

• Leaks? Look under lift

  Safe

  At Risk

  N/A

• Horn

  Safe

  At Risk

  N/A

• Gauges

  Safe

  At Risk

  N/A

• Brakes

  Safe

  At Risk

  N/A

• Lights

  Safe

  At Risk

  N/A

• Attachments and accessories

  Safe

  At Risk

  N/A

• Steering

  Safe

  At Risk

  N/A

• Back up alarm or warning buzzer

  Safe

  At Risk

  N/A

• Warning lights

  Safe

  At Risk

  N/A

• Lift and travel control switches

  Safe

  At Risk

  N/A

• Placards, decals and control ID present and legible

  Safe

  At Risk

  N/A

• Handrails, guardrails and safety chains

  Safe

  At Risk

  N/A

• Platform deck and toe boards

  Safe

  At Risk

  N/A

• Electrical lift cords are in good condition

  Safe

  At Risk

  N/A

• WEDNESDAY

• Type of lift

  Select Scissor Mast Articulated Boom

  • Scissor
  • Mast
  • Articulated Boom

• Model#

• Oil Level

  Safe

  At Risk

  N/A

• Hydraulic oil level

  Safe

  At Risk

  N/A

• Fuel level

  Safe

  At Risk

  N/A

• Ground control switches

  Safe

  At Risk

  N/A

• Tire condition

  Safe

  At Risk

  N/A

• Coolant level

  Safe

  At Risk

  N/A

• Batteries

  Safe

  At Risk

  N/A

• Leaks? Look under lift

  Safe

  At Risk

  N/A

• Horn

  Safe

  At Risk

  N/A

• Gauges

  Safe

  At Risk

  N/A

• Brakes

  Safe

  At Risk

  N/A

• Lights

  Safe

  At Risk

  N/A

• Attachments and accessories

  Safe

  At Risk

  N/A

• Steering

  Safe

  At Risk

  N/A

• Back up alarm or warning buzzer

  Safe

  At Risk

  N/A

• Warning lights

  Safe

  At Risk

  N/A

• Lift and travel control switches

  Safe

  At Risk

  N/A

• Placards, decals and control ID present and legible

  Safe

  At Risk

  N/A

• Handrails, guardrails and safety chains

  Safe

  At Risk

  N/A

• Platform deck and toe boards

  Safe

  At Risk

  N/A

• Electrical lift cords are in good condition

  Safe

  At Risk

  N/A

• THURSDAY

• Type of lift

  Select Scissor Mast Articulated Boom

  • Scissor
  • Mast
  • Articulated Boom

• Model#

• Oil Level

  Safe

  At Risk

  N/A

• Hydraulic oil level

  Safe

  At Risk

  N/A

• Fuel level

  Safe

  At Risk

  N/A

• Ground control switches

  Safe

  At Risk

  N/A

• Tire condition

  Safe

  At Risk

  N/A

• Coolant level

  Safe

  At Risk

  N/A

• Batteries

  Safe

  At Risk

  N/A

• Leaks? Look under lift

  Safe

  At Risk

  N/A

• Horn

  Safe

  At Risk

  N/A

• Gauges

  Safe

  At Risk

  N/A

• Brakes

  Safe

  At Risk

  N/A

• Lights

  Safe

  At Risk

  N/A

• Attachments and accessories

  Safe

  At Risk

  N/A

• Steering

  Safe

  At Risk

  N/A

• Back up alarm or warning buzzer

  Safe

  At Risk

  N/A

• Warning lights

  Safe

  At Risk

  N/A

• Lift and travel control switches

  Safe

  At Risk

  N/A

• Placards, decals and control ID present and legible

  Safe

  At Risk

  N/A

• Handrails, guardrails and safety chains

  Safe

  At Risk

  N/A

• Platform deck and toe boards

  Safe

  At Risk

  N/A

• Electrical lift cords are in good condition

  Safe

  At Risk

  N/A

• FRIDAY

• Type of lift

  Select Scissor Mast Articulated Boom

  • Scissor
  • Mast
  • Articulated Boom

• Model#

• Oil Level

  Safe

  At Risk

  N/A

• Hydraulic oil level

  Safe

  At Risk

  N/A

• Fuel level

  Safe

  At Risk

  N/A

• Ground control switches

  Safe

  At Risk

  N/A

• Tire condition

  Safe

  At Risk

  N/A

• Coolant level

  Safe

  At Risk

  N/A

• Batteries

  Safe

  At Risk

  N/A

• Leaks? Look under lift

  Safe

  At Risk

  N/A

• Horn

  Safe

  At Risk

  N/A

• Gauges

  Safe

  At Risk

  N/A

• Brakes

  Safe

  At Risk

  N/A

• Lights

  Safe

  At Risk

  N/A

• Attachments and accessories

  Safe

  At Risk

  N/A

• Steering

  Safe

  At Risk

  N/A

• Back up alarm or warning buzzer

  Safe

  At Risk

  N/A

• Warning lights

  Safe

  At Risk

  N/A

• Lift and travel control switches

  Safe

  At Risk

  N/A

• Placards, decals and control ID present and legible

  Safe

  At Risk

  N/A

• Handrails, guardrails and safety chains

  Safe

  At Risk

  N/A

• Platform deck and toe boards

  Safe

  At Risk

  N/A

• Electrical lift cords are in good condition

  Safe

  At Risk

  N/A

• SATURDAY

• Type of lift

  Select Scissor Mast Articulated Boom

  • Scissor
  • Mast
  • Articulated Boom

• Model#

• Oil Level

  Safe

  At Risk

  N/A

• Hydraulic oil level

  Safe

  At Risk

  N/A

• Fuel level

  Safe

  At Risk

  N/A

• Ground control switches

  Safe

  At Risk

  N/A

• Tire condition

  Safe

  At Risk

  N/A

• Coolant level

  Safe

  At Risk

  N/A

• Batteries

  Safe

  At Risk

  N/A

• Leaks? Look under lift

  Safe

  At Risk

  N/A

• Horn

  Safe

  At Risk

  N/A

• Gauges

  Safe

  At Risk

  N/A

• Brakes

  Safe

  At Risk

  N/A

• Lights

  Safe

  At Risk

  N/A

• Attachments and accessories

  Safe

  At Risk

  N/A

• Steering

  Safe

  At Risk

  N/A

• Back up alarm or warning buzzer

  Safe

  At Risk

  N/A

• Warning lights

  Safe

  At Risk

  N/A

• Lift and travel control switches

  Safe

  At Risk

  N/A

• Placards, decals and control ID present and legible

  Safe

  At Risk

  N/A

• Handrails, guardrails and safety chains

  Safe

  At Risk

  N/A

• Platform deck and toe boards

  Safe

  At Risk

  N/A

• Electrical lift cords are in good condition

  Safe

  At Risk

  N/A

• SUNDAY

• Type of lift

  Select Scissor Mast Articulated Boom

  • Scissor
  • Mast
  • Articulated Boom

• Model#

• Oil Level

  Safe

  At Risk

  N/A

• Hydraulic oil level

  Safe

  At Risk

  N/A

• Fuel level

  Safe

  At Risk

  N/A

• Ground control switches

  Safe

  At Risk

  N/A

• Tire condition

  Safe

  At Risk

  N/A

• Coolant level

  Safe

  At Risk

  N/A

• Batteries

  Safe

  At Risk

  N/A

• Leaks? Look under lift

  Safe

  At Risk

  N/A

• Horn

  Safe

  At Risk

  N/A

• Gauges

  Safe

  At Risk

  N/A

• Brakes

  Safe

  At Risk

  N/A

• Lights

  Safe

  At Risk

  N/A

• Attachments and accessories

  Safe

  At Risk

  N/A

• Steering

  Safe

  At Risk

  N/A

• Back up alarm or warning buzzer

  Safe

  At Risk

  N/A

• Warning lights

  Safe

  At Risk

  N/A

• Lift and travel control switches

  Safe

  At Risk

  N/A

• Placards, decals and control ID present and legible

  Safe

  At Risk

  N/A

• Handrails, guardrails and safety chains

  Safe

  At Risk

  N/A

• Platform deck and toe boards

  Safe

  At Risk

  N/A

• Electrical lift cords are in good condition

  Safe

  At Risk

  N/A

• STOP AND CONTACT YOUR SUPERVISOR FOR DIRECTION IF PRE TASK PLAN CANNOT BE MET
  
  STOP AT ONCE IF CONDITIONS CHANGE DURING THE COURSE OF WORK

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What to do at completion of Checklist - DO NOT TAP ON "NEXT SECTION"

• At completion of this "Pre Task Planning checklist Audit", do not tap "Next Section",
  1 - Tap " EXPORT" in lower right corner of screen BELOW "Next Section",
  2 - Tap "SEND" in upper right hand corner of box that pops up
  3 - Enter mnahas@fluidics.com in the To: field.
  4 - Tap Send.
  5 - after sending email tap Save and Close in the upper left hand corner of screen

VEHICLE INSPECTION

• Current registration and insurance card in center console

  Yes

  No

  N/A

• Inspection stickers on windshield current

  Yes

  No

  N/A

• Mirrors present and functional

  Safe

  At Risk

  N/A

• Windshield and wiper blades

  Safe

  At Risk

  N/A

• Seat belts functional

  Safe

  At Risk

  N/A

• Oil and coolant levels checked and ok

  Yes

  No

  N/A

• Steering functional

  Safe

  At Risk

  N/A

• Horn

  Safe

  At Risk

  N/A

• Tires - take pictures as needed by tapping on the + symbol

  Good

  Fair

  Poor

• Brakes, and emergency brake

  Safe

  At Risk

  N/A

• Exhaust leaks/noises

  Safe

  At Risk

  N/A

• Headlights working and adjusted appropriately

  Safe

  At Risk

  N/A

• Turn signals functional

  Yes

  No

  N/A

• Emergency flashers functional

  Yes

  No

  N/A

• Brake lights functional

  Yes

  No

  N/A

• License plate lights functional

  Yes

  No

  N/A

• Reverse lights functional

  Yes

  No

  N/A

• Vehicle fire extinguisher present and inspected (tag, pin in place, tie wrap on pin, needle in the green on gauge)

  Yes

  No

  N/A

• First aid kit present and stocked

  Yes

  No

  N/A

• Cargo area tidy. Material stored secured and able to be retrieved with minimal lifting and bending.

  Yes

  No

  N/A

• Dashboard and Passenger area clear of loose material

  Yes

  No

  N/A

• Stickers:<br><br>Current Missing Kids poster <br>How's My Driving Decal on Bumper<br>Walk Around Before Your Drive Around sticker on drivers side window above door handle<br>EMCOR Injury And Safety Data Sheet hotline sticker on lower dash in the area of left leg

  Yes

  No

  N/A

• Drivers Name and Signature:

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What to do next

• At completion of this "Vehicle Inspection Checklist", do not tap "Next Section",
  1 - Tap " EXPORT" in lower right corner of screen below "Next Section",
  2 - Tap "SEND" in upper right hand corner of box that pops up
  3 - Enter mnahas@fluidics.com in the To: field.
  4 - Tap Send.
  

Pre-Task Planning Guide

• Pre task planning g guide should be completed daily for each task. Post in a conspicuous location throughout the length of the task. Each employee involved with the task shall initial the this guide. If deviation from known work practices/procedures occurs, work must be stopped and re-evaluated. On project sites notify your supervisor and/or safety.

• Project Name:

• Supervisor:

• Date:

  Date

• Location of task:

• Task description:

• Does the task require special training?

  Yes

  No

  N/A

• If so, what type?

Task information

• What are the hazards associated with the job/task?

• What will be done to eliminate/control the above hazards

• Have they been reviewed by affected employees

  Yes

  No

  N/A

General Work Environment/Housekeeping

• Is there acceptable access/egress to the work site? Tripping hazards removed/addressed?

  Yes

  No

  N/A

• Materials handling:Should carts or other means be used to keep materials off of floor?

  Yes

  No

  N/A

• Is there adequate illumination for all work?

  Yes

  No

  N/A

• Barricades maintained & appropriate?

  Yes

  No

  N/A

• What weather conditions could effect safe performance of this task

  Select Rain Wind Snow Ice NA

  • Rain
  • Wind
  • Snow
  • Ice
  • NA

• Are trash receptacles available in the work area? Water and sanitations located?

  Yes

  No

  N/A

• Location?

Fire Protection

• Location of nearest fire extinguisher and communication source?

• Are flammable/combustible materials stored, separated, inspected, labeled and secured per procedure?

  Yes

  No

  N/A

Tools and Equipement

• Use inspection is required on all tools, ladders, GFCI, electrical cords, rigging, and safety equipment. Has this been accomplished?

  Yes

  No

  N/A

Material Storage

• Has a material storage area been identified and approved?

  Yes

  No

  N/A

Fall Protection

• Have areas been identified as requiring fall protection systems? (i.e. - static lines, barricades, handrails, holes, covers, etc.)

  Yes

  No

  N/A

• 100% tie off require?

  Yes

  No

  N/A

• What height?

Personal Protective Equipment

• Eye/face protection Z87 glasses, goggle, face shield

• Head protection

• Hand protection - gloves, leather, gauntlet, cut or chem resistant

• Garment/coveralls - traffic vest, Nomex, Tyvek

• Knee/shin/foot (safety toe, rubber, knee pads)

• Fall protection harness

• Welding - goggle, hood, sleeves

• Respirator - dust, welding, half, full, full, supplied air.

• NFPA 70E - Arc Flash protection

• Other:

Equipment

• List mechanized equipment, platforms,, personnel lifts, and scaffolds.

• Do they have current inspections?

  Yes

  No

  N/A

Employee certifications required

• Crane Operator

• Forklift Operator

• Mobile equipment Operator

• Aerial Lift

• Powder Actuated Tool

• NFPA 70E

• Competent Person

• Confined Space

• Excavations

• Hazardous Materials/Waste Operations

• Scaffold erection/Dismantlement

• Other:(Specify)

Procedures/Permits Required

• Lock out Tag out

• Hot Work

• Fire Watch

• Fire Watch

• Excavation

• Signs/Barricades

• Permit Required Confined Spaces

• Hole watch

• Crane Lift

• Line Break

• Scaffolds

• Other: (Specify)

Post Task Assignment

• Supervisor

• Select date

  Date

• Was anyone injured or did an unplanned event occur?

  Yes

  No

  N/A

• If yes, explain. Who, what, when, where, why?

• Was it reported to Management/Safety

  Yes

  No

  N/A

• To who and when?

• What problems did you have with today's work assignment?

• What can we do to improve safety/performance?

• Miscellaneous concerns?

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• Supervisors Signature

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• Project Manager Signature

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• Technician Signature

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What to do next

• At completion of this "Pre Task Planning Guide", do not tap "Next Section",
  1 - Tap " EXPORT" in lower right corner of screen below "Next Section",
  2 - Tap "SEND" in upper right hand corner of box that pops up
  3 - Enter mnahas@fluidics.com in the To: field.
  4 - Tap Send.
  

EM&FS Safety Orientation Checklist

• The Responsible Manager, Authorized Supervisor, or Safety Representative shall ensure that new and transferred personnel have completed this Safety Orientation. Supervisors and affected personnel shall acknowledge each requirement contained herein by signature at the end of this form.

Hazard Communication/Global System of Harmonization

• Identified the Hazardous Communication Job Site Coordinator

  Yes

  No

  N/A

• Identified the location of the Site Specific Written Hazcom Program

  Yes

  No

  N/A

• Identified the location of Safety Data sheets and provided employee with EMCOR 888 number to obtain one.

  Yes

  No

  N/A

• Identified work location/owner requirements for chemical use and storage

  Yes

  No

  N/A

Emergency Action Plans

• Identified location specific emergency action plan

  Yes

  No

  N/A

• Identified employees specific emergency action plan responsibilities

  Yes

  No

  N/A

• Identified method or system for contacting emergency services

  Yes

  No

  N/A

Energy Isolation and Electrical Safety

• Identified requirements for working near energized equipment or parts

  Yes

  No

  N/A

• Identified location and use of locks, tags and lock out devices

  Yes

  No

  N/A

• Identified work location specific lock out tag out program and location of equipment/system isolation practices.

  Yes

  No

  N/A

• Date for electrical Safety Training

  Date

General Safety Issues

• Identified location of Safe Work Practices

  Yes

  No

  N/A

• Personal protective equipment (PPE) location and use.

  Yes

  No

  N/A

• Identified requirements for operating company issued or work location vehicles.

  Yes

  No

  N/A

• Identified requirements for reporting work related injuries, damage to equipment/property damage. Provided employee with 800# wallet card

  Yes

  No

  N/A

• Identified disciplinary actions for violating work location safety requirements

  Yes

  No

  N/A

• Received orientation of www.emcor.net Safety Training and Resource STAR Page

  Yes

  No

  N/A

Other Site Specific Requirements

Signatures

• Employee

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• Supervisor

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• NOTE: Completed forms shall be maintained at the Operating Unit and made available to EMCOR Safety Regional Directors as requested.

What to do next

• At completion of this "New Hire Orientation", do not tap "Next Section",
  1 - Tap " EXPORT" in lower right corner of screen below "Next Section",
  2 - Tap "SEND" in upper right hand corner of box that pops up
  3 - Enter mnahas@fluidics.com in the To: field.
  4 - Tap Send.
  

Mandatory Safe Work Practices

• Always Lock Out and Tag Out energized equipment and verify zero energy state before commencing work. ALL WORK PERFORMED MUST BE AT A ZERO ENERGY STATE.

• Use proper Personal Protective Equipment, PPE. "If you are working, you are wearing!": Eye Protection, Hand Protection, Head Protection, etc.

• Always maintain three points of contact when ascending or descending ladders.

• Do not carry out work if you do not have the proper tools and equipment for the job and/or environment.

• Always refer to the Pre-Panning Checklist before starting a project or service call.

• Always use appropriate fall restraint or protection when within 15 feet of a fall of 6 feet or greater.

• Always report unsafe conditions to your immediate supervisor.

• Always wear seat belts and obey all traffic laws when operating a vehicle.

• Never begin a skilled task or operate equipment and machinery unless properly trained and qualified.

• NEVER consume or be under the influence of alcohol or illegal drugs while at work, and inform your supervisor, or Human Resources, if you are prescribed any medication that has impairment warnings.

What to do next

• At completion of this "Mandatory Safety Rules Checklist", do not tap "Next Section",
  1 - Tap " EXPORT" in lower right corner of screen below "Next Section",
  2 - Tap "SEND" in upper right hand corner of box that pops up
  3 - Enter mnahas@fluidics.com in the To: field.
  4 - Tap Send.
  

EM&FS FIELD SAFETY INSPECTION REPORT

• Date of Inspection

  Date

• Site Name

• Site Address

• Employee(s)

• Inspector

• Foreman

• 2 - Meets Requirements
  1 - Needs Improvement
  0 - Totally Unacceptable
  NA - Not Applicable

Health and Welfare

• First Aid supplies available

  2

  1

  0

  N/A

• Hand washing materials and/or facilities available.

  2

  1

  0

  N/A

• Safety Data Sheets and Safe Work Practices Manual available

  2

  1

  0

  N/A

• Emergency preparedness/Evacuation Route

  2

  1

  0

  N/A

• Safety Bulletin Board present. Be Vigilant Postings and GWP;s posted

  2

  1

  0

  N/A

Housekeeping

• Good site layout of materials.

  2

  1

  0

  N/A

• Site access/dust control

  2

  1

  0

  N/A

• Site housekeeping - controls

  2

  1

  0

  N/A

• Trash containers available, used and emptied

  2

  1

  0

  N/A

• Materials stacked and stable

  2

  1

  0

  N/A

• Flammable/Combustibles stored/access clear

  2

  1

  0

  N/A

• All boards de-nailed or nails bent over.

  2

  1

  0

  N/A

• Passageways/walkways clear.

  2

  1

  0

  N/A

• Floor holes covered, identified, and secured

  2

  1

  0

  N/A

• Cords/cables routed properly out of walkways.

  2

  1

  0

  N/A

Personal Protective Equipment

• Head Protection worn at all times

  2

  1

  0

  N/A

• Eye protection appropriate for hazards.

  2

  1

  0

  N/A

• Foot protection - hard soled leather boots

  2

  1

  0

  N/A

• Hearing protection appropriate for the hazards

  2

  1

  0

  N/A

• Hand protection appropriate for the hazards

  2

  1

  0

  N/A

• Respiratory Protection as required for tasks

  2

  1

  0

  N/A

• Chemical protection appropriate for the hazards

  2

  1

  0

  N/A

• Chemical Protection appropriate for the hazards

  2

  1

  0

  N/A

• Fall protection

  2

  1

  0

  N/A

• Proper clothing

  2

  1

  0

  N/A

• NFPA 70E PPEavailable/used

  2

  1

  0

  N/A

Employee Work Observations

• Employees wearing correct PPE fo tasks

  2

  1

  0

  N/A

• Employees working on lifts properly

  2

  1

  0

  N/A

• Fall protection worn in lifts

  2

  1

  0

  N/A

• Employees were handling material properly

  2

  1

  0

  N/A

• Work stations were at correct heights

  2

  1

  0

  N/A

• Lifting and movingdevices were available

  2

  1

  0

  N/A

• Employees observed using ladders properly

  2

  1

  0

  N/A

• No materials carried ascending/descending ladder

  2

  1

  0

  N/A

• Employees operating equipment were trained

  2

  1

  0

  N/A

• Employees using fall protection properly

  2

  1

  0

  N/A

• Pre-Task planning form used before starting project

  2

  1

  0

  N/A

• Hazardous Energy Control (lock out tag out)

  2

  1

  0

  N/A

• NFPA 70E Arc Flash procedures

  2

  1

  0

  N/A

• Confined Space entry controls in place

  2

  1

  0

  N/A

• Hazard Communication labeling res. in use.

  2

  1

  0

  N/A

Hand Tools

• Correct hand tools used for task observed

  2

  1

  0

  N/A

• Defective tool program in use

  2

  1

  0

  N/A

• 2

  1

  0

  N/A

• No make shift tools in use

  2

  1

  0

  N/A

Power Hand Tools

• Defective tool program in use

  2

  1

  0

  N/A

• Properly grounded or double insulated

  2

  1

  0

  N/A

• Ground fault circuit interrupter in use

  2

  1

  0

  N/A

• Properly guarded at all times

  2

  1

  0

  N/A

• Inspections of electrical cords and connectors

  2

  1

  0

  N/A

• Correct disc/Speed/Size/Type

  2

  1

  0

  N/A

Ladder, Ramps, and Stairs

• Ladders inspected before use

  2

  1

  0

  N/A

• Ladder design and use correct for task

  2

  1

  0

  N/A

• Secured at top and/or base

  2

  1

  0

  N/A

• Side rails extend 3' above top of platform

  2

  1

  0

  N/A

• Rungs not over 12" on center and regular spacing

  2

  1

  0

  N/A

• Ramps cleated

  2

  1

  0

  N/A

• Stairways completed for use

  2

  1

  0

  N/A

• Handrails provided as required

  2

  1

  0

  N/A

• Elevation changes of 19" - Ramp or steps provided

  2

  1

  0

  N/A

Environmental

• Universal waste labeled, separated, and stored properly

  2

  1

  0

  N/A

• Used lamps and ballasts

  2

  1

  0

  N/A

• Used batteries

  2

  1

  0

  N/A

• Used refrigerant order

  2

  1

  0

  N/A

• Used electronic circuit boards

  2

  1

  0

  N/A

• Used mercury switches

  2

  1

  0

  N/A

• List other universal waste opinion comments section below

EMCOR Truck/Van

• Good housekeeping

  2

  1

  0

  N/A

• Compressed gas cylinders are capped and secured

  2

  1

  0

  N/A

• Emergency road kit on board

  2

  1

  0

  N/A

• Fire extinguisher on board

  2

  1

  0

  N/A

• Tools and materials properly tied down, no bungee cords

  2

  1

  0

  N/A

• Ladders properly secured to roof rack, no bungee cords

  2

  1

  0

  N/A

• Hazardous chemicals labeled and properly stored

  2

  1

  0

  N/A

• Cab is clean and contents secured.

  2

  1

  0

  N/A

Fire Prevention/Protection

• Adequate fire extinguishers for hazards

  2

  1

  0

  N/A

• Proper type and location

  2

  1

  0

  N/A

• Fire watches trained and posted where required

  2

  1

  0

  N/A

• No smoking signs posted

  2

  1

  0

  N/A

• Inspection and maintenance - monthly

  2

  1

  0

  N/A

• Fire extinguisher use reported

  2

  1

  0

  N/A

• Flammable materials in approved containers

  2

  1

  0

  N/A

• Flammable distribution systems are grounded

  2

  1

  0

  N/A

Safety Permits

• Obtained as required/monitored, hot work, etc.

  2

  1

  0

  N/A

• Smoking control in areas with flammable materials

  2

  1

  0

  N/A

• Fire extinguishers - as required on permit

  2

  1

  0

  N/A

Welding/Cutting

• Cylinders secured and upright

  2

  1

  0

  N/A

• Gauges removed during relocation (individual).

  2

  1

  0

  N/A

• Conditions of hoses inspected daily

  2

  1

  0

  N/A

• Fire extinguishers - 10 ABC minimum within 50 feet

  2

  1

  0

  N/A

• Personal Protective Equipemtn

  2

  1

  0

  N/A

• Welding shields in use

  2

  1

  0

  N/A

• Grounding - close to work station

  2

  1

  0

  N/A

• Cables conditions inspected/rolled up - not in use

  2

  1

  0

  N/A

• Hot work permits issued as required

  2

  1

  0

  N/A

• Equipment off when not in use

  2

  1

  0

  N/A

• Machine frame grounded

  2

  1

  0

  N/A

• Flash back arrestors installed - torch/gauge

  2

  1

  0

  N/A

Scaffolding

• Erection/dismantlement supervised by a competent person

  2

  1

  0

  N/A

• Designed properly for height/weight

  2

  1

  0

  N/A

• Connections secured

  2

  1

  0

  N/A

• Platforms full width - 2x10's planks and secured

  2

  1

  0

  N/A

• Scaffold tied to structure every 20'

  2

  1

  0

  N/A

• Platform free of debris

  2

  1

  0

  N/A

• Base pads used/castors locked

  2

  1

  0

  N/A

• Scaffolds plumb and braced

  2

  1

  0

  N/A

• Guardrails 42" high/stable and toe board

  2

  1

  0

  N/A

• Material in good condition - no knots, splintering

  2

  1

  0

  N/A

• Mobile scaffold - stationary/no riders

  2

  1

  0

  N/A

• Safe access/fall protection provided/used

  2

  1

  0

  N/A

• Anchored, safety harness's tied off

  2

  1

  0

  N/A

• Scaffold properly inspected/tagged

  2

  1

  0

  N/A

Powder Actuated Tools

• Appropriate eye protection being used

  2

  1

  0

  N/A

• Ear protection as required

  2

  1

  0

  N/A

• Control of cartridges -authorized persons

  2

  1

  0

  N/A

• Equipment used per manufacturers recommendations

  2

  1

  0

  N/A

• Trained and qualified operator

  2

  1

  0

  N/A

• Inspection and maintenance of equipment

  2

  1

  0

  N/A

• Sign posted where being used

  2

  1

  0

  N/A

Cranes And lifting

• Operator qualified/certification

  2

  1

  0

  N/A

• Qualified riggers/signal person when required

  2

  1

  0

  N/A

Inspectors comments. Document and critical observations, serious safety violations observed, employees counseling, required deficiency training and or disciplinary action.

• Comments

Employee/Supervisor/Foreman Comments

• Comments

Signatures

• Inspector

  Sign

• Supervisor/Foreman

  Sign

• Employee

  Sign

What to do next

• At completion of this "EM&FS Field Safety Assessment", do not tap "Next Section",
  1 - Tap " EXPORT" in lower right corner of screen below "Next Section",
  2 - Tap "SEND" in upper right hand corner of box that pops up
  3 - Enter mnahas@fluidics.com in the To: field.
  4 - Tap Send.
  

Root Cause Analysis Worksheet

• Date of Investigation:

  Date

• Date of Injury:

  Date

• Investigator Name:

• Job Site Name:

• Injured Employee Name

• 1. Injury Event: Describe the situation (injury, illness, other losses). Pinpoint the problem and describe.

• 2. Sequence of Events: Develop sequence of events from start to finish, based on interviews and physical evidence. Describe each event as an occurrence with one noun/verb. Describe the events precisely as they happen.

• 3. Injury Analysis: (direct cause). Analyze the injury event to identify and describe the direct cause of the injury.

• 4. Event Analysis: (indirect cause-acts/conditions). After the sequence of events is established, the cause of each event can be described. This involves asking why, why, why, why, why. You do not need to ask questions for all events in the sequence, just the ones critical for understanding the cause. Determine indirect causes (hazardous conditions and unsafe behavior) from the sequence of events.

• 5. System Analysis: (root cause).The last step is to find the root causes. The procedures, standards, controls that management did not design or failed to implement. Continue asking “why” in order to develop the information needed to establish root causes. Root causes are usually not physical things. They are program and/or related behavioral inadequacies. Determine system design and system implementation causes for each of the indirect causes.

• 6. Corrective Action: List the Corrective Action to avoid future occurrences.

• Take or import supporting photos here:

  Media

What to do next

• At completion of this "Root Cause Analysis worksheet", do not tap "Next Section",
  1 - Tap " EXPORT" in lower right corner of screen below "Next Section",
  2 - Tap "SEND" in upper right hand corner of box that pops up
  3 - Enter mnahas@fluidics.com in the To: field.
  4 - Tap Send.